Circumcision in the United States of America

In the United States circumcision emerged at the same time as in Britain and for much the same reasons: hostility to masturbation, delusions about congenital phimosis, fear of diseases like syphilis and cancer. But it got its biggest boosts from the two world wars and from the medicalisation of childbirth. The importance of both the obstetricians/gynecologists and the the military in the promotion of circumcision in the USA cannot be overestimated.

Although experts in venereal diseas such as Abraham Wolbarst had called for universal circumcision as early as 1914 [1], it was the obstetricians and gynecologists who were responsible for realising his dream. It may seem strange that the most important advocates of routine male circumcision within the medical profession were experts in women's health, who knew little and cared less about male anatomy, but from the 1930s onwards it was the obstetricians and gynecologists who most vigorously touted the advantages of the procedure and performed most of the operations. Symptomatic of their power was the introduction of the Gomco clamp by the obstetrician Hiram Yellen, who wanted a device that was so simple to use that his colleagues would be able to claim the circumcision procedure from fussy and expensive surgeons who still insisted on anaesthetics and strict control of bleeding. The result was that circumcison came to be seen as part of the birth process, often performed within a day or even a few hours of the boy's arrival in the world - a procedure no more surgical or problematic than tying his umbilical cord [2].

So obsessed did these specialists in women's bodies become with altering male bodies that it was not unknown for them to circumcise the poor boy before he had even fully emerged from the womb. The authors of a book on childhood diseases report: "The practice of circumcision has become almost universal in the United States.... Some obstetricians have made early circumcision almost a fetish, reaching it to a reductio ad absurdum in one instance with which we are familiar in which the operation was performed when the hips been delivered and pending expulsion of the upper half of the body." [3]

Miltary discipline

The US military was another important influence. Around the turn of the last century, circumcision of infants was still rather rare, though circumcision of older boys was gaining in popularity. During World War I, the military led a concerted effort to circumcise soldiers and sailors because it was believed that this would make them less susceptible to venereal disease; military discipline forced men to submit to a procedure they would never have agreed to had it been left to their own decision. Thousands of men were circumcised in their late teens and early 20s. When these men returned home and became fathers, doctors began asking whether they wanted their newborn sons circumcised. Many, remembering the pain that they or their buddies endured from the operation as adults, said yes, thinking it would avoid having to do it later, when the pain was thought to be worse than in infancy. Most babies, however, continued to be born at home and were not circumcised.

By the outset of World War II, the USA had circumcision rates of about 40-50 per cent and Britain 30 to 40 per cent. Most sources agree that circumcision in the UK continued its climb until just about the outbreak of war. After the Second World War, there was a remarkable split in circumcision rates in the USA and Britain. The UK was absolutely ravaged from war – there were no spare resources anywhere. The National Health Service, which had originally been planned for the 1930s and delayed, finally came into being quite shakily in July 1948. Most people predicted its imminent failure. While circumcision was theoretically "included" in the free procedures, most physicians had real trouble justifying it in the climate of near-poverty. There was thus no financial incentive for unnecessary surgery.

Role of medical insurance

In the USA, there was rapid development and prosperity after World War II. One consequence of this was the shortage of labour for all the newly-created jobs. From the early 1950s, companies began offering lavish benefits packages to lure employees, and it became standard for them to include full, private health insurance as a condition of employment. Thus, there was no need for the US government to even investigate starting a national health scheme as long as there was full employment and companies were falling over each other to provide the most lavish plans.

Almost all of these private insurance packages paid for male infant circumcision, then considered to be quite a progressive and good thing to do. The USA saw a tremendous rise in the number of hospital births after the war, and it became a sign of backwardness to have a child at home. Even the poorest citizens arranged to have their babies in hospital. During the 1950s the rate of routine infant circumcision exploded from about 50 per cent to about 90 per cent. This was also fuelled by the popular press, such as Dr. Benjamin Spock's Baby and Child Care. Nearly every American family had (has!) this bible of child care on their bookshelf. In the earliest editions, appearing just after World War II, Dr. Spock argued that circumcision is a very good idea, particularly if the other boys in the neighbourhood were also cut. Caring for the baby would then be easy, and he'll grow up feeling "regular" (i.e., not eccentric, different or in any other way un-American – it is a very conformist culture). In the 1980s Spock recanted this advice and suggested that being intact was just fine and that parents should leave baby boy’s penises alone. But it was harder to stop a trend than to start it.

In 1959 the circumcision rate in the USA was about 90 per cent. It was very rare to see a foreskin in the changing room. Those that did have one also usually had a story: born premature, to immigrant parents, or overseas and came to the USA as children. In Britain the incidence of neonatal circumcision declined to less than 5 per cent by the early 1950s. During this same period, it was skyrocketing in the USA. The biggest difference was probably around 1960, when hardly any British boys were cut and nearly every American boy got circumcised. The difference is illustrated in the contrasting answers given to the question "Should the baby be circumcised?" by the American obstetrician Alan Gutttmacher in 1941 and the British surgeon Sir Daniel Whiddon in 1953.

This past weekend I was up in Vancouver, Canada for their last good beach days of the summer. Wreck Beach is one of North America's largest nude beaches, and it sits right on the campus of the University of British Columbia. I've been going there every summer for the past 16 years, and have noticed a marked change in the college students. They guys now seem to be about 50/50 cut/uncut, which is very different from the 80% cut I was seeing in the 1980's. By my estimates, most undergraduates at UBC are now intact, and soon it will be something like 3/4 uncut. This reflects the rapid decline of circumcision in Canada in the early 1980s.

This is such a contrast to the USA for various reasons. One, of course, is that more than a million baby boys still get circumcised every year in the USA - most within the first 24 or 48 hours of life. Second is the fact that "modesty" has reached insane levels in the newly-conservative USA, unlike most other countries. High schools have been ripping out shower rooms with a vengeance during the past 10 years as boys refuse to undress in front of one another, and parents have begun to sue school districts for invasion of privacy (forcing boys to reveal their private bits to one another in gym class). Now kids just stink as they go from gym class to history class. Even the athletes do not shower after practice after-school: they ring Mom to come get them so they can shower alone at home, out of view of their mates. The net effect of this is that most American males born today will never see another male naked in their lives until, and if, they have a son of their own. If they see him at birth they will certainly view his long, tapering penis as something quite strange and probably regard it as unnatural. Even then, quite a few American males will go to their graves never having seen a penis other than their own. My guess is that this is going to turn the country even more neurotic than it is, and makes issues like stopping circumcision more difficult. Whilst the "locker room" argument now holds no water, circumcised men are more afraid than ever of the unknown.

A puzzling situation

Why routine circumcision persists in the USA, long after it has been largely or entirely abandoned by the other anglophone countries which originally took it up, remains a puzzle. How deeply embedded in modern American culture it seems to be is indicated by a story told by the paediatrician Robert Van Howe, who reports that he once spent hours resuscitating and assessing the injuries of a boy who had been born unable to breathe, without a pulse, and with a broken humerus and depressed skull fracture resulting from a difficult forceps delivery. He then visited the mother, whose first question was “When can he be circumcised?”

Such a sense of priorities sharply indicates the privileged place of male circumcision in modern America and highlights the difficulties in explaining what Edward Wallerstein has called “the uniquely American medical enigma”. Despite statements from the American Academy of Pediatrics and the College of Obstetricians and Gynecologists in 1971, 1975, 1978 and 1983, he noted in 1985 that the practice had abated little. Even today, after further statements in 1989 and 1999, the operation is performed on well over half of all of newborns.

Van Howe suggests seven lines of inquiry. (1) The foreskin is the focus of myths, misconceptions and irrationality affecting medical profession and public alike. (2) Lack of respect for the rights and individuality of children. (3) A contrasting exaggerated delicacy with respect to the presumed sensibilities of religious minorities which practise circumcision for cultural reasons. (4) The reluctance of physicians to take a firm stand against circumcision and to refuse parental requests. (5) Bias in American medical journals, which tend to favour articles with a pro-circumcision tendency and are reluctant to publish critiques, much less developed arguments against. (6) Failure to subject circumcision to the normal protocols for surgery, such as the need for informed consent, evidence of pathology and proof of prophylactic benefit. (7) Strong financial incentives to perform the operation, usually guaranteed by medical insurance coverage.

The last of these points has been stressed by a number of critics. In their analysis of Medicaid funding, Amber Craig and colleagues found that low and declining rates of circumcision correspond to regions where the procedure is not funded, most noticeably in California.

The market for medical services

As David Gollaher and any analysis of the economics of medicine have shown, doctors are not disinterested scientific observers, but professionals selling a service in return for a fee. The rapid spread and obstinate survival of circumcision in the USA may thus be related to a probable chronic oversupply of doctors there, an aspect of the bloated medical industry which the vast wealth of the world’s richest nation is able to sustain. American physicians seem have always been short of well-paying patients, sharply on the look-out for little jobs offering a good return, and consequently liable to invent new disease conditionss requiring frequent trips to the surgery. Many of the nervous syndromes of the late Victorian period – hysteria, neurasthenia, spinal irritation, reflex neuroses, congenital phimosis and preputial adhesions in male and female – can be accounted for in no other way. Dr Robert Morris suggested in 1892 that since 80 per cent of American women suffered from adhesions which bound the clitoris to the prepuce and produced many bodily disturbances, female physicians should be required to inspect the genitals of all schoolgirls to ensure that proper separation between prepuce and clitoris had occurred. He was confident that most of the girls would require surgery, and this was a good thing, since it provided work for female doctors: “The separation of adhesive prepuces in young unmarried women should be done by female physicians anyway, and such physicians can be abundantly occupied with this sort of work”. [4]

This desperate search for something to do, and someone to do it to (in a word, new and bigger markets for medical services) in turn feeds and is fed by the illusion that universal perfect health is an achievable goal: all that is needed are more funds for medical research, more health services, more doctors, more programs etc. Alas, the goal of perfect health for all is as unattainable as perfect happiness or a perfect partner for everybody: with avoidable medical accidents the eighth most common cause of death in the USA, it is probable that more illness and injury are caused by chasing this chimaera than by accepting the limits of health and beauty that one’s genes and environment have determined.

On the inflated importance of both health and sickness in the world today, see:

Even in the USA, however, more doctors are realising that it is unnecessary, harmful and unethical to deprive baby boys of their foreskin unless there is an immediate medical problem that can only be corrected in that way. For an indication of the trend of American mendicalthinking, see a recent article by Dr Roxanne Allegretti, of Fredericksburg, Virgina.

3. Robert Morris, "Is evolution trying to do away with the clitoris?", Transactions of the American Association of Obstetricians and Gynecologists, Vol. 5, 1892, p. 293. Morris had of course been inspired by the argument of P.C. Remondino, in his History of circumcision from the earliest times: Moral and physical reasons for its performance (1891), that this was exactly what evolution was trying to do with the male foreskin - though found itself in need of a helping hand from surgeons like him.

Further reading

Frederick Hodges, “A short history of the institutionalization of involuntary sexual mutilation in the United States”, in George C. Denniston and Marilyn Milos (eds), Sexual mutilations: A human tragedy, New York, Plenum Press, 1997